Monthly Archives: February 2015

“My vendor holds my data hostage, and I have to pay a ransom to access it,” said a primary care physician from Oregon in a Politico report.

This is the largely shared sentiment by many professionals in the healthcare industry who are pushing for interoperability but face financial barriers from IT vendors. As the federal government continues to push for digitized records, interoperability and shared data, physicians are finding the EHR records stuck and siloed by individual vendors who charge them to share data. Physicians pay anywhere between $5,000 and $50,000 to set up the infrastructure to allow for data sharing, either transmitting information to laboratories or connecting to HIEs, according to the report.

“The No. 1 factor hindering the exchange of information between healthcare stakeholders is the exorbitant fees that most EHRs are charging for integration, connectivity and reporting,” said Lance Donkerbrook, COO of Tempe, Ariz.-based Commonwealth Primary Care ACO in the report.

According to the report, vendors argue they don’t have any customer demand to participate in interoperability, to which physicians largely disagree, many of which are required to be interoperable to meet meaningful use requirements.

It seems vendors will be unlikely to address interoperability because it makes little business case for them to address it. To illustrate, EHR provider NextGen Healthcare’s sales revenue fell from $149 million in 2012 to $87 million in 2014. However, its data interchange fees increased during that same time period from $49 million to $67 million, according to the report.

To combat the vendor pricing, Rep. Michael Burgess (R-Texas), MD, who leads the House Energy and Commerce trade subcommittee, is drafting a bill to require interoperability. “It’s unfair that practitioners have to spend money on connections they thought were part of the EHR when they bought it,” he said in the report.

Rep. Burgess told Politico that he believes this issue will be resolved in the marketplace, but legislators are examining what legislation might look like if it isn’t ultimately resolved.

As they move to exchange patient information with hospitals and other health care partners, doctors are suffering sticker shock: The vendors of the health care software want thousands of dollars to unlock the data so they can be shared.

It may take an act of Congress to provide relief.

The fees are thwarting the goals of the $30 billion federal push to get doctors and hospitals to digitize health records. The exorbitant prices to transmit and receive data, providers and IT specialists say, can amount to billions a year. And the electronic health record industry is increasingly reliant on this revenue.

The goal of the 2009 program wasn’t just to move doctors from paper chart to computer. It was also to share the information, improve the quality of patient care and ultimately bring down U.S. health care costs.

Most doctors and hospitals have now switched to electronic health records, or EHRs. But the information is often stuck in computers run by hundreds of competing health care software companies — with incompatible products and scant incentive to make them compatible, or “interoperable,” as the industry calls it.

The additional costs were not foreseen during the bipartisan congressional push to create the federal incentive program. The expense is now imperiling the broad efforts to reform health care and adding to the host of technical obstacles that already hamper the flow of information.

“I believe this to be the biggest threat to the investment the nation has made in health IT,” said David Kendrick, head of Oklahoma’s health information exchange, which links doctors, hospitals and labs in his state. “All the money spent on electronic health records has yielded only a fraction of the value of getting interoperability.”

“It’s like giving everyone cellphones and not putting up a cell tower,” he added.

GOP congressional leaders are usually reluctant to intrude on business practices. But in this case, some GOP lawmakers are considering sanctions on the software vendors.

“Interoperability is what makes an EHR useful,” said Rep. Michael Burgess (R-Texas), a physician who leads the House Energy and Commerce trade subcommittee and is drawing up a bill to enforce data sharing. “It’s unfair that practitioners have to spend money on connections they thought were part of the EHR when they bought it.”

And it’s frustrating to physicians trying to tap into the promise of real-time electronic patient information. “My vendor holds my data hostage, and I have to pay a ransom to access it,” said an Oregon primary care doctor.

The potential of shared data to improve the quality of care while containing costs was one big reason the federal government paid doctors to get electronic health records. Getting that information in real time lets doctors keep tabs on their sickest patients.

That Oregon doctor, for example, could learn immediately when a diabetic patient entered an ER with a foot infection, rather than finding out a week later — when it was too late to make sure he got out of the hospital fast with the right medications to take home.

When data sharing works, it has good results. “The minute any one of my patients is seen at a hospital or gets an X-ray, the result goes immediately to my electronic health record,” said Ed Bujold, a western North Carolina family doctor.

An affiliated hospital system waived a $10,000 fee to set up Bujold’s electronic pipeline. But in general, doctors pay $5,000 to $50,000 each for the privilege of setting up connections allowing them to transmit information regularly to blood and pathology laboratories, health information exchanges or governments, according to more than a dozen sources interviewed for this story. Sometimes additional fees are charged each time a doctor sends or receives data.

“The No. 1 factor hindering the exchange of information between health care stakeholders is the exorbitant fees that most EHRs are charging for integration, connectivity and reporting,” said Lance Donkerbrook, chief operating officer of Commonwealth Primary Care ACO, an affiliation of 250 independent physicians. They can’t share information because they have 30 different EHRs among them, and each vendor wants $7,500 to $40,000 to connect them, he said.

“The government needs to step in immediately and require these vendors to open access,” he said.

The Electronic Health Records Association, which represents most vendors, would not comment on companies’ pricing policies. But it said the connections were expensive because of the lack of common computer-code standards across the hundreds of EHR manufacturers.

“As with other areas of health care, variability increases costs, and all stakeholders in health care need to work together to reduce this variability and the factors that drive it,” said Sarah Corley, the association’s vice chairwoman and chief medical officer of NextGen Healthcare.

Some question EHR makers’ commitment to easier access. New York and 18 other states spent five years creating simple standards for EHRs to link to health information exchanges in order to eliminate the need to connect with individual EHRs through individual interfaces — “each one a handcrafted engineering problem that costs thousands of dollars and takes weeks if not months of engineering to connect,” said David Whitlinger, executive director of the New York eHealth Collaborative.

Vendors took part in creating the standards, but when it came time for them to certify their products, they declined to participate, Whitlinger said.

“They all said, ‘We don’t have any customer demand for those,’” he said. “We said, ‘We beg to differ.’ No one came right out and said it, but if you look at the [EHR companies’] financials, you see they are making lots of money from building their own interfaces.”

Farzad Mostashari, an architect of the incentive program who now runs a business helping set up alliances to improve care quality, angrily raised the issue of high fees this month at a meeting of the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC), which he led from 2011 to 2013.

The practices that he advises want to share data but “can’t get their own data out,” Mostashari said. They pay $10,000 to be able to transmit clinical care documents, “not because of technical standards, but because of business practices. The vendors don’t have the same incentives as the providers do.”

Mostashari’s successor at the ONC, Karen DeSalvo, acknowledged the problem in response to a similar complaint at a conference the next day. His was a “common refrain,” she said, that “Congress has asked us to do something about.”

The problem came into sharper focus over the past year as doctors began seeking to meet the latest stage of the electronic health records incentive program. It requires them to share data with other doctors, and to do that they need their software vendors to build computer interfaces.

In the past, doctors might have wanted the connections but weren’t obliged to have them. Now they have a hard time meeting federal requirements without them.

As incentive payments started to dry up last year, EHR vendors began to see fewer sales of new software. They seem to have become more reliant on consulting contracts and fees.

For example, EHR maker NextGen and its parent company saw sales revenue decrease from $149 million to $87 million from 2012 to 2014. The company’s data interchange fees, meanwhile, increased from $49 million to $67 million.

On a national scale, the fees mount up. If each of the country’s 230,000 medical practices pays $15,000, on average, to connect to a health exchange, the cost to the health care system is roughly $3.5 billion. Many physicians need multiple interfaces.

The ONC has a certification program that requires vendors to show that their software will enable providers to meet the requirements of the federal incentive program, which in its current stage includes the ability to share data.

But the office has no power to set or police the prices that vendors charge. That leaves Congress in a bit of a quandary. Should it intervene in the market?

“I realize that I have to pay a fee when I use an ATM that isn’t part of my bank,” said Burgess. “But you can’t just drop your EHR like a used car and get another one.”

The systems cost thousands or millions of dollars and take months to implement. The favored term for this condition is “market failure.”

“This should be resolved in the marketplace,” said Burgess. But if it isn’t, he said, “ what would legislation look like? We’re examining that question very closely.”

“Some would say, let market forces reign and it will take care of itself. But it will take care of itself only at the expense of the public good,” said Whitlinger, who compares the situation to the earliest days of cellphones, when those made by different companies couldn’t communicate with one another.

Last year, I wrote about my sister-in-law Patricia who was pregnant with her first child and wondering how she could track health information for both her and her newborn. With this simple request, she was exposed to the state of interoperability in the health care industry.

She could not access her doctor’s electronic health record (EHR) through her personal health record, nor could she communicate electronically with her prospective pediatrician. At the time, it was a small concern, but that quickly changed after she delivered. Her newborn’s breathing problems prompted an extended stay in the NICU, multiple diagnostic procedures, consultations by numerous specialists and use of a host of monitoring devices in the hospital and following discharge.

Suddenly the challenge of interoperability was very real for her.

Many in the health care industry (and providers in particular) have long been frustrated by the lack of interoperability among health systems and IT vendors, medical devices and financial systems. Earlier this month, the Office of the National Coordinator for Health IT (ONC) took a step toward advancing interoperability by publishing the initial draft of “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap.”

The draft calls for ONC to ensure that four important actions are completed in the short term:

Establishing a governance framework for interoperability that includes “overarching rules of the road” and involves a public/private process for implementation

Improving standards and guidance so they are “scalable, high performing and simple”

Using policy and funding levers to create incentives to use common technical standards to share health information technology

Some items within the roadmap are particularly notable. This roadmap is the first detailed vision the federal government has provided to the industry of a path toward system-wide interoperability. The ONC has received criticism inside and outside the beltway for not taking a stronger stance on interoperability earlier in the Meaningful Use program.

The draft also outlines how health plans can help advance interoperability. As organizations move from a volume- to value-based reimbursement model that needs to rely on population health management to a greater extent, connecting clinical and financial data will be essential. As an example, health plans with a focus on value-based care could make interoperability a condition of participation for providers seeking to partner with them in new payment arrangements.

This roadmap also identifies where the current issues lie and what may need to happen to allow the industry to get there. The “Standards Advisory,” which ONC is now soliciting public comments on, provides some of those details. This model will allow the industry to identify where stakeholders agree and disagree on standards and encourages an open dialogue on how to reach consensus on the points of disagreement.

While the roadmap provides a number of answers, it also raises a number of questions:

How will medical devices fit in? This roadmap focuses primarily on EHRs, but some providers struggle to integrate data from a wide range of devices. Integrating medical devices is very costly for health systems but can also impact patient safety.

What will be the future of health information exchanges (HIEs)? This perennial question around the purpose and sustainability model of HIEs becomes more acute as one of their primary functions – combining data in one place – may be rendered unnecessary by systems that speak with each other seamlessly.

Will EHR vendors have to change their systems or even their business models? The value of many lies in the comprehensiveness and integration of their various modules. How will free flow of data across vendors impact this competitive edge? Will interoperability become an opportunity for smaller players and will it help foster innovation generally?

How will the roadmap be enforced? Who will enforce agreed upon standards? How will we know when interoperability has been achieved? Simply certifying technology against criteria is not the same as certifying that something actually works. Health care may draw on experiences from other industries that have adopted centralized labs to test products in a real-world environment to measure this.

What will be the broader impact on the health care ecosystem? Information flow is not just about solving technical issues of interoperability, but also touches on complex regulatory, privacy and commercial factors.

Thankfully, Patricia’s son made a complete recovery and is thriving today. The ONC has declared a goal of 2017 to achieve significant progress, so hopefully by the time he is ready to go to pre-school, many of these issues will have been resolved.

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